A nurse is assisting with the care of a client who has pneumonia.
For each potential nursing action, click to specify if the potential action is anticipated or contraindicated for the client.
Apply a cool compress to the extremity.
Assist in inserting a new IV catheter in a site distal to infiltration site.
Elevate extremity.
Administer phytonadione.
Send the catheter tip for culture.
Suggest irrigating the IV catheter.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"B"}}
Anticipated:
- Apply a cool compress to the extremity. A cool compress can reduce swelling, relieve discomfort, and help minimize the tightness in the skin caused by edema. The cold temperature helps constrict blood vessels, reducing fluid buildup in the tissues. This intervention is appropriate for managing IV infiltration-related symptoms.
- Assist in inserting a new IV catheter in a site distal to the infiltration site. If the IV site becomes infiltrated, the correct approach is to stop the current infusion and insert a new catheter in a different location, preferably distal to the infiltration site. This ensures continued IV access without further aggravating the infiltrated site.
- Elevate extremity. Elevating the affected extremity can help reduce swelling by promoting venous return. Elevation improves circulation and decreases the pressure caused by fluid accumulation in the tissues. This is an effective intervention for managing swelling in the right upper extremity due to infiltration.
Not Anticipated:
- Phytonadione (vitamin K) is typically used to reverse the effects of anticoagulation medications or treat vitamin K deficiency. This is not indicated for the client, as there is no evidence of bleeding or an anticoagulation issue that requires vitamin K. The client's current problem is an IV infiltration, not a clotting disorder.
- Send the catheter tip for culture. At this point, there are no signs of infection such as redness, warmth, or discharge from the IV site. The primary concern is managing the infiltration, so sending the catheter tip for culture is unnecessary unless infection is suspected. Culture collection is reserved for cases where an infection is present.
- Suggest irrigating the IV catheter. Irrigating an infiltrated IV catheter could worsen the situation by pushing fluids further into the surrounding tissue or introducing bacteria. The proper action is to discontinue the infusion, remove the IV, and insert a new catheter at a different site rather than attempting to irrigate an already compromised catheter.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Rigid abdomen. A rigid or board-like abdomen is characteristic of placental abruption, not placenta previa. Placental abruption involves premature separation of the placenta from the uterine wall, leading to significant abdominal pain and uterine tenderness. In contrast, placenta previa typically presents with painless bleeding.
B. Increased fetal movement. Fetal movement is not directly affected by placenta previa unless there is severe hemorrhage leading to fetal distress. While decreased movement in cases of significant bleeding may indicate fetal compromise, increased movement is not a typical finding.
C. Persistent uterine contractions. Placenta previa does not usually cause persistent contractions. While mild uterine irritability may occur, placenta previa is primarily characterized by painless bleeding. Persistent contractions are more commonly associated with preterm labor or placental abruption.
D. Bright red vaginal bleeding. The hallmark sign of placenta previa is painless, bright red vaginal bleeding in the second or third trimester. This occurs due to the placenta covering or being near the cervical os, leading to bleeding as the cervix begins to dilate or efface.
Correct Answer is A
Explanation
A. An advanced practice nurse, such as a nurse practitioner or clinical nurse specialist, has the training to assess medication interactions and adjust prescriptions if necessary. They can evaluate the client's medications, consider potential adverse effects, and collaborate with the prescribing provider. Consulting an advanced practice nurse ensures safe and effective medication management.
B. A psychologist focuses on mental health assessment and therapy but does not prescribe or manage medications. They may help clients cope with medication-related concerns, but they lack the authority to assess or modify prescriptions. Medication-related inquiries should be directed to a medical provider or pharmacist.
C. A social worker assists clients with psychosocial needs, financial concerns, and community resources but does not have the expertise to evaluate medication interactions. They can provide support for medication access or adherence issues but not clinical medication guidance. Medication safety requires consultation with a qualified medical professional.
D. A patient care technician provides basic client care, such as vital sign monitoring and assisting with activities of daily living. They do not have the training to assess medication interactions or provide pharmacological advice. Medication concerns should be referred to a licensed healthcare provider.
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